'IN MY END IS MY BEGINNING'
The Changing Context of Psychoanalytically-oriented Consultancy

Introduction

The early years of working life of most of us here today were a time of hope - the peace movement, civil rights, women's liberation, participation in the workplace, and welfare provision. Growing up in the United States and Britain in the 50's and 60's, we 'knew' that employment and promotion were sure, as long as we were prepared to work for it; for the educated middle classes, the main question was how fulfilling a career we could plan for ourselves. Change was assumed to be for the good, often the greater good; after all if change was not about making things better, then there would be no reason to change. It was also the era of the individual: finding oneself, fulfilling one's potential - with widespread engagement with psychoanalysis and a host of other therapies and emotional development programmes.

Over the past couple of decades we have seen a considerable crumbling, in human service provision generally, and psychoanalytically based treatments in particular. In the United States insurance companies no longer paying for extended therapy and analysis has led to a severe decline of private practice, while in Britain dwindling resources have meant that public sector providers such as the National Health Service (NHS) or colleges and universities offer ever less long-term treatment. Shorter-term alternative therapies, many of them borrowing substantially from the psychoanalytic tradition even while criticising it, have gained in popularity. At the same time, the workplace has become unpredictable, even unrecognisable, as organisations restructure and downsize over and over: far from looking forward to promotion as inevitable, we can no longer be sure of being employed at all, let alone be fulfilled by our careers. The large human service systems - health, education, social services - are providing less and less to more and more, with demand outstripping resources everywhere. Through our work in the public sector we are only too aware of the widespread lack of job satisfaction, the rising tide of desperation, and the sense of lots of fingers stuck in lots of dykes.

This is being met to a considerable extent by denial, people continuing to talk and behave as if the current changes were temporary, a blip before we return to the steady state, rather than being indicative of massive irreversible trends. The polar caps are melting, not for a season or a decade, but as the beginning of a new era; it is our belief that our social systems are breaking up under the weight of trying to operate on the basis of outdated models and assumptions. For example, denial of the degree of change means that many teachers are trying to teach ever larger classes of children with increasingly complex needs using the same methods as before, and hospital staff are spending a huge proportion of their time desperately looking for beds for patients in need of admission. The favoured remedies would seem to be listening to each child read for less time each week, or altering discharge criteria to shorten patients' length of stay in hospital - tinkering with the old systems while waiting for the next election to increase resources so that things can get back to normal. Charles Handy (1989) uses the image of the frog which, if placed in boiling water, would jump out, but when placed into cold water which is then gradually heated up to boiling point makes no move to save itself. The water is getting hotter, but we behave as if we need only survive the discomfort for a time.

Since, however, we are not frogs, we do adapt to the changing temperature, adopting different defences even if we do not fundamentally alter our views of the context within which these changes are taking place. In the 1980's, people studying organisations began to comment on the phenomenon of psychological withdrawal from work, as redundancies and associated casualties became widespread. Given how fused self-esteem and sense of self are with work identity, the risk to individual well-being of losing one's job is considerable. Even for those still in employment, their relatedness to their employing organisation began to shift dramatically, partly to cope with the constant changes in their organisations, partly in an attempt to feel prepared for whatever might hit them next. Far from causing employers consternation at the hidden costs of this psychological withdrawal, it seems to have been actively encouraged in many instances, for example by tendering out services which were previously provided internally, or making staff redundant only to hire them back in as consultants - often at a higher rate of pay but without commitment on either side.

Losing one's job brings with it loss of the defences against psychotic (paranoid-schizoid) anxieties which the organisation provided; losing familiar structures, working practices and colleagues brings about a not dissimilar loss. Stokes (1994) notes, for example, how aggression in the workplace tends to be directed more at individuals when the departments we used to hate no longer exist. One prevalent response has been a psychological withdrawal from work, reducing libidinal investment to avoid burnout and anguish. Closely linked with this is another phenomenon: the development of portfolio careers, reinvesting one's energy to be ready to move on to the next project, managing oneself by keeping dependency to a minimum and hiring oneself out as 'Me Ltd.'. even when one is technically a full-time member of staff. Thus on the one hand we find employees becoming more compliant, as well as more disaffected, especially at lower levels of the organisation; on the other hand, senior personnel, typically on short-term contracts, often operating in maverick ways, focused on short-term outcomes, and with no binding psychological work contract (Miller 1995).

Inevitably, this is accompanied by changing attitudes to leadership. Freud (1921) wrote of the surrendering of the ego-ideal to the leader, unconscious anxieties about survival elevating leaders into saviours of mythical proportions. This is less than typical of the world of work as we now know it. People in leadership positions may still have vision, but there is less and less followership. Rather we find disillusion - sometimes enraged, sometimes apathetic - but certainly a disinclination to believe enough in anyone to follow them with commitment, not least because today's boss may be history in a month or two, and the new boss will have other ideas. Similarly, bonding to one's work group also seems to be on the decline (Roberts 1994). Efforts to motivate the workforce and win loyalty through induction, slogans or mission statements often seem to have a reverse effect, fuelling cynicism, mockery and resentment.

Added to all this, we are living in a society that through most of our lifetime's has had a readily identifiable external hated object that was available for our bad projections. This was so from the 1930's when National Socialism was rampant through to the fall of communism in recent history. However, we now live in a society that no longer has such a clearly defined external enemy available for these societal projections. So where do these projections get located? It would appear that central government is rapidly becoming the receptacle for these projections, the bad breast which deprives instead of feeding us. Obviously, this has implications for any organisation such as the NHS that is funded and controlled by central government.

In an age of such complexity, turbulence, even chaos, roles require psychological 'presence' or - to borrow Winnicott's (1971) term, 'pre-occupation' - more than ever. This means that tasks and roles need to be meaningful, and that the environment must be experienced as providing some safety. This will not be the old safety of stability and job permanence - the work-force are not children to be lulled with fairy tales. But we do feel that we should strive for a work-place where it is safe to think, where we can look forward to being heard, and therefore can re-discover a position from where we can make a meaningful contribution. Of late there has been endless experimentation with different organisational structures such as flattening hierarchies, devolving budgets, and multiple leadership. But playing with external structures is not enough; indeed, we suggest this cannot work unless there are alternative containers for anxiety, new ways of meeting dependency needs, and other sources of meaning are also found.

In the remainder of this paper we shall be focusing on the British National Health Service. As the largest employer and as an organisation with which every citizen inevitably has contact,it serves as a good example to illustrate the phenomena we have been describing.

The British National Health Service

Starting in 1984 the NHS has been the subject of what seems like a continual restructuring process. Prior to 1984 staff were accountable to multidisciplinary Hospital Management Committees which made decisions largely by consensus. These Committees were accountable to District and Regional Health Authorities. Then, general management was introduced with the aim of increasing accountability through devolving budgets and authority, with a view to increasing efficiency and effectiveness. General managers, rather than senior clinicians, now ran the health service. During the next five years the experience was one of constant change as local restructuring was repeated over and over, to the point where some staff gave up trying to work out who was really in charge.

In 1989, The NHS Reforms and Community Care Act introduced the so-called purchaser-provider split. The old Health Authorities were divided into two parts; the purchasers of health services, responsible for assessing the health care needs of the local population and buying services, and the providers of health services such as hospitals. This was designed to stimulate competition since purchasers were now able to negotiate contracts with any hospital or NHS organisation, not just the one in their area. The rationale being that by introducing such competition, performance would be further improved and patients' needs better met.

As part of this latter change, service providers were encouraged to form NHS Trusts, 'self-governing' units that would manage the budgets they negotiated with purchasers. By 1994 most NHS provision came from Trusts. Each Trust has its own Chief Executive and Management Board and they vary in size from about 1000 personnel to 5000. The Board is led by a Chair appointed by the Secretary of State for Health.

These reforms have had a number of effects, not least an acute awareness at all levels that decisions have financial implications, and that these influence what choices - including clinical decisions - will be made. However, NHS Trusts are part of a society in which there are ever increasing demands and expectations for health care, yet where resources are severely limited. The pressure of these dilemmas, and the consequences of short term attempts to try to resolve them, impinge on managers and staff at every level, and contribute to distress and organisational dysfunction.

Rather than feeling empowered (e.g., by devolved budgets), most Trust employees seem to feel strait-jacketed, as if they are now working to a primary task other than that which motivated them to enter the NHS - an accountancy task or a political agenda. Accountability for quality is experienced more as an exercise in bureaucracy than a reality, while money for staff training and development, and time for reflection are in ever shorter supply. Loyalty gradually wanes as staff increasingly feel their organisations, the government, the system as a whole demand more and more while offering less and less. The following vignettes provide a flavour of the NHS as experienced in various Trusts.

A senior physician talks to a consultant about his current experience of work - of being snowed under by paperwork and bureaucracy, endless internal and inter-agency meetings often filled with strife; being invited to show enthusiasm for new projects like the recent launch of a new quality standards system, when what pre-occupies him is the diminishing amount of time he has for patients - the erosion of everything that gave his job meaning - so that now, at 47, he is counting the days to early retirement. 'It is no longer my NHS', he concludes sadly, though adding that it may feel different to his younger colleagues who have 'grown up' in the current system. The consultant leaves the meeting filled up with a profound desolation which persists for many hours.

In the same Trust, the consultant also meets a general manager whose enthusiasm about the new community services she is setting up is very infectious. She will be employing a number of new staff to lead the community teams and asks if the consultant can help her. The locality is to be transformed, its old-fashioned practices modernised, it will be a model. Three months later, she has left for a promotion in another part of the country, leaving the new system which she has managed largely by personal energy and charisma in a state of breakdown. One casualty was a newly-appointed team leader who felt totally unable to manage without her support, particularly in the face of acting out in his team and personal attacks on himself which seemed to be fuelled by the team's anxiety at the manager's departure.

A new community Trust spends a great deal of time, energy and money to bring in a supervision/appraisal system, training senior staff to use it to develop staff as well as services. There is a desperate need for good supervision, as staff reel from one restructuring after another, and the expectations on them keep changing. But a year later many staff are still receiving supervision sporadically as both supervisors and supervisees continually cancel sessions because of pressures of work.

A hospital has recently restructured its senior management system, and further restructuring is likely in a few months as merger negotiations are under way, so they appoint a temporary director. The head of nursing is also a temporary appointment. The director asks the consultant to provide team development for the new senior management team. The consultant asks, what would constitute a good outcome. His reply: for them to share his sense of this being the dawn of a new era. But is it? How can it be when two out of the five key people are on six-month contracts, and the hospital may not exist as a separate entity at the end of that time? The invitation seems to be to bolster denial, rather than seeking how to contain the anxieties engendered throughout the hospital by so much uncertainty. Yet it is hugely seductive to engage in these 'dawn of a new era' projects.

These vignettes illustrate a number of the issues raised in the introduction. They also give evidence of a 'gap in the middle': managers on the whole tend to be young, energetic, keen and hopeful, senior clinicians generally older, seem to be jaundiced, in touch with the pain of their patients and also of the pain of never having enough to give, criticised externally for long waiting-lists and otherwise inadequate services, but even more sharply censured from within themselves for not meeting the traditional standards of their profession. Rage and blame are rife, but also guilt and despair. Trust headquarters, bright, busy and neat; the wards and clinics gloomy, shabby, even squalid. Meetings designed to bring senior managers and clinicians together do little to reduce this gap. It is as if something even more awful might happen if the two really shared their pre-occupations, as if managers could not function if they got too near the pain of the patient-staff interface, or clinicians could not function if they found out too much of the reality driving health service decisions and could not simply blame managers and planners. (McCaffrey 1996)

The question we pose is: how do we as psychoanalytically-oriented consultants position ourselves in relation to all these stresses and complexities? How can we offer interventions which are relevant - and perceived to be relevant - to the health service of the 1990's? The problems presented to us, and the wider context within which our clients are working, is significantly different from what they were a few years ago. In the next two sections, we will try to address these questions, drawing on our respective experiences of consulting in the NHS, the first author as an internal consultant with an organisation relatively receptive to a psychodynamic way of working, the second author as an external consultant often negotiating with organisations sceptical or even overtly resistant to such an approach. To avoid cumbersome language, these sections are written in the first person.

Negotiating in a Receptive Climate

This part of the paper is written from the perspective of being a member of a small internal consultancy unit within an NHS Mental Health Trust over a period of about a year and a half. Such units are not uncommon in the NHS but usually employ people from training or OD backgrounds, whereas this team employed one occupational psychologist and two clinicians - a psychiatrist and a psychologist, both trained as psychoanalytic psychotherapists and both experienced practitioners of psychoanalytically-informed organisational consultancy. The clinical training of two members made us relatively expensive; however, the organisation seemed to value our hands-on familiarity with the realities of working with very disturbed patients, as well as the understanding of unconscious processes in organisations and the non-directive stance we brought from our analytically-oriented training.

One of the things that struck me most forcibly when I first started in this job was the contrast between the managers that I met and my previous expectations. These expectations derived in part from my past clients, grass-roots staff who described managers as totally out of touch with the realities of clinical work. But I had also assumed from my work in the NHS some years previously that the managers would be naïve about unconscious processes in organisations, and probably sceptical and resistant. To my surprise, they were on the whole quite sophisticated about unconscious processes, and generally well aware of the stresses of the work their staff were carrying out. I found that the ideas I brought to our meetings met with recognition, resonating far more readily with people's experiences and pre-occupations than had been the case a few years before. I discovered that many directors and other senior managers were graduates of executive development programmes that included a significant exposure to psychodynamic theories and experiential learning about group and organisational behaviour. This often made negotiating work a pleasure, but also presented new challenges. What exactly was I offering to this new breed of managers that they could not provide for themselves?

Example 1. One of the very first projects I was asked to undertake was to try to improve the relations between a community-based residential unit and the hospital from which it received its referrals. The staff of the house complained that they were not receiving enough suitable referrals and that they had difficulty getting psychiatric input when their residents' mental state deteriorated. Managers at the hospital complained that the staff of the house took an unwarrantably long time assessing referrals, turned down the difficult cases, and were too quick to ask for psychiatric intervention and re-admission for their residents.

The director who first approached me about this seemed to be making every effort to be impartial, and from her account it sounded like a fairly straightforward two-party conflict. I then visited the hospital managers who told me essentially the same story: they felt that the home was 'creaming off' the 'easy' cases, leaving the more disturbed patients to stay in hospital far longer than was necessary. When I visited the manager of the home, I heard a very different story, so different in fact that I felt for a while as if I were Alice after she went through the looking-glass. It appeared that since its opening two years before the home had turned down only two referrals, one who was too physically disabled to manage the stairs, and one who was well known to the other residents and whom they refused to live with. Where was the unreasonableness? Where were the hordes of rejected referrals? This could not be the whole story. Painstakingly, the house manager and I went through the files of every single person who had been referred. It transpired that there had indeed been a considerable number of referrals which had not led to placement, but not because the home had turned them down. In several instances it was because Social Services, who were the purchasers for the places in this home, had done their own assessment of the person being referred and had not agreed to pay for the placement. In a few instances, the person referred had turned down an offered place because they preferred to live elsewhere.

It was evident that an intervention based on seeing this as a two-party problem was doomed to failure. I therefore suggested that before doing any further work, we set up a steering group comprising representatives from all three agencies concerned: the home, the hospital and Social Services. I had anticipated that I would be briefed by this steering group, would then design an intervention to improve intergroup relations, and then report back to them. Instead, from the very first meeting they became a problem-solving group, and nothing more was required from me beyond facilitating half a dozen further meetings of the group at six-weekly intervals.

While it is not uncommon to find issues framed in diadic rather than triadic terms (Foster 1993), I think this case study illustrates a particular resistance in this system to acknowledging the key role of the purchaser, which in this case was Social Services. So long as the hospital managers could blame the staff of the home, they could deny the unpalatable - and relatively new - fact of their dependence on another agency. However, as long as Social Services were kept out of the discussions, the problem could not be resolved.

Example 2. A community mental health team asked for an 'awayday' to review their aims and working practices. This was an annual event for them, but the first time I had been involved. The team leader felt under a great deal of pressure because of conflicts among different sub-groups within his team about what the priorities of the service should be. There was also conflict between his team and other teams providing services in the locality, notably around how clients were referred between services.

Neither of these issues, it seemed to be, could be adequately addressed by this team alone, since they were neither in a position to determine their priorities for themselves (that is, without reference to the requirements of senior managers and purchasers), nor could they determine the working practices of the other teams working on the patch. Yet if the day were opened to include others, I was warned, the team was likely to feel 'their' time had been hijacked by a superordinate agenda, an all too-frequent-experience for them and which was likely to fuel resentment rather than being helpful. In the end, the team leader's line manager was invited to one of the four sessions to provide information about Trust and purchasers' priorities, and to clarify the team's scope of discretion with regard to this. Representatives from two other local teams were invited to another of the sessions to contribute to a 'mapping' exercise, identifying what services were available to the local population and where the gaps and overlaps were. This proved very fruitful and seemed to free up the team to tackle some of their internal issues in the afternoon, as well as to consider what further inter-agency planning they needed to set up.

Here again we see a powerful wish to maintain an illusion of autonomy by denying dependence on purchasers and managers, and interdependence with other providers. However, the cost of such denial is very high, not only in terms of effectiveness but also of morale, as the conflict gets acted out within the team. Indeed, in this case as in many others I have encountered, the denial of some of the more painful realities of the purchaser-provider split and the new marketplace orientation of the public sector had led to scapegoating of individuals and sub-groups within the team who were blamed for its lack of progress.

In both of these examples I was in a position to negotiate a rather different brief from the one originally proposed to me, partly because of my position of being internal to the Trust while being external to the immediate client unit. This meant firstly that I was not dependent on the particular contract: my salary cheque would come regardless. I also had credibility deriving from the reputation of our unit. And not least, the clients were probably more prepared to listen to unwelcome views without 'killing the messenger' because if they wanted to use another consultant they would have to pay! Finally, the cumulative experience gained from consulting to many different parts of this large and complex system meant that I was aware of issues beyond those of the locality, and could use this knowledge to engage more effectively with the immediate problems being presented. The reverse was also true, that what I learned from these pieces of work could be fed back to others or used to inform other consultancy projects. Indeed, gradually the work of our team shifted from being primarily responsive to requests for help to being more often proactive, ourselves identifying where and how we might most usefully deploy ourselves.

Negotiating Consultancy in a Competitive Climate

This section is written from the perspective of directing an independent consultancy service which has over the past eighteen months undergone a shift in emphasis: from mainly responding to localised requests for consultancy services, to proactively designing and marketing large system interventions to address the problem of organisational stress within the NHS. We have worked in several Trusts, and interest in our model continues to grow. However, in the course of negotiating with different Trusts, we have learned some hard lessons about how to bridge the gap between our way of thinking and that of clients. Not surprisingly, I have a different view than that of my co-author about growing receptivity as a general phenomenon, although I believe this to be so.

Our consultancy service is part of OPUS (An Organisation for Promoting Understanding in Society) which uses experiential learning in the tradition of the Tavistock Institute to study societal dynamics. As consultants, we maintain a particular interest in the wider social context within which our clients are operating and how societal dynamics affect organisational functioning. The NHS, by virtue not only of its size but also of its life-and-death role in everyone's lives, is particularly likely to be thus affected

This has implications for the way that organisational dysfunctions are viewed and diagnosed. Brought up in a world of science that has taught generations of people to be concerned with validity, reliability, and objectivity, we should not be surprised that many clients are looking for a consultancy 'product' that is divided up into elements which are easily quantifiable and replicable, a form of 'boxed' product which will take away the uncertainty and anxiety of not knowing, one which they feel they can control.

Many senior executives are still very much dominated and influenced by concepts of organisations as rational systems. Thoughts of psychodynamic causation are easily dismissed as 'nonsense' and far fetched.

In many ways this parallels the difficulties experienced by psychosomatic patients; despite the fact that over a century ago Freud developed concepts such as unconscious conflict, defences and resistance, and through his theory of 'conversion' described how nervous energy was repressed and transformed into bodily symptoms, these patients are still frequently dismissed as having no legitimate cause for complaint. Sanders (1996) describes the typical course of events: the general practitioner attempts to diagnose or eliminate organic disease repeatedly sending the patient for further investigations. This pattern may be driven by the doctor's doubts about whether organic disease can be entirely ruled out and reluctance to make an alternative, non-organic diagnosis, or by the patient's resistance to letting go of a purely physical explanation of their symptoms.

Many organisations today are sharing similar experiences to these psycho-somatic patients. They too may have a long history of seeking help and going through managerial and consultancy change programmes which have not helped their problems and may even have done some harm. As a result the client feels frustrated, distressed, angry and disillusioned with the ability of others to help them. They have had numerous interventions for all manner of thing that have used up a large amount of resources, both human and financial, but have not resolved the problem, and this has led to further distress and dysfunction. This is certainly true of many NHS organisations that have a long history of interventions many of which could be described as 'quick fixes'. Why should this be so? Why should perfectly sensible managers act in this way on repeated occasions? I believe that we have the beginnings of an answer to these questions if we return to the analogy that I introduced above where both the psychosomatic patient and the doctor focus on the surface symptom and fail to look for the underlying psychological causes. So too is the case with organisations where they often seek solutions to what they see as rational surface issues and fail to explore the underlying psychodynamic issues.

These 'rational' solutions are frequently pursued in a relentless almost crazy manner. For example, at a seminar for NHS Executives I was running a small group where the discussion turned to who had tried which fashionable OD intervention. Nearly all of the agencies represented had invested in a long list of interventions such as quality circles or briefing groups. As they discussed the various initiatives, one person would ask, 'Has anyone done (so-and-so) yet?' to which others would respond, 'Yes, it doesn't work'. The first speaker would then announce, 'Oh, we're starting it next week.' It seemed that they would proceed with the initiative regardless of, even totally denying, other people's experience.

Like the doctor that tries to treat the psycho-somatic patient by providing remedies for organic symptoms, organisations also try to isolate an identifiable cause and provide a remedy. For example, they carry out a stress audit and then provide counselling and stress modules to all staff; or they provide leadership training or a module on communication; or (a favourite in many organisations) they create a new organisational structure. Re-structuring an organisation will seem a perfectly natural response to a host of perceived problems to managers influenced by organisational behaviour literature founded on non psycho-dynamic approaches.

Most of us here today have a different view of organisations, seeing them as processes of human behaviour. As such, we need to take an approach that permits us to identify and interpret underlying psychodynamic processes. This, of course, has huge implications for working with organisations that are influenced by the old scientific approach where the client expects us to tell them exactly what we are going to do and how long it will take. We may well feel that we cannot provide this information until we start working in the organisation, that is, we cannot give them the boxed product they so desire. Yet in many tightly controlled organisations it would be inviting immediate rejection to offer a product which to them seemed totally uncontrollable; this is one essential tension with which we have to work. To try to sell them a product that is open-ended and to speak of dynamic processes, rather than offering the more familiar closed-ended and objectively-based product that they are used to, will not provide them with the minimum confidence to go ahead. Should they feel that they have no control whatsoever over the consultancy process (for which they are accountable and for which they might be subject of considerable criticism), they will be unlikely to agree to its adoption.

If chaos is defined as uncertainty about boundary definition, or more colloquially, as not knowing who, or what belongs where, then 'every transaction is potentially chaotic' (Rice, 1976). In these circumstances it is hardly surprising that these organisations should look for simplistic or even magical solutions to their problems. And it is not perhaps surprising that they should cling to the familiar even when it seems obvious to the outsider that the familiar has ceased to be appropriate or relevant. To the members of the organisation, who are part of the culture, the familiar will be both relevant and appropriate. Furthermore, so long as they could hold on to the view that the current situation was only a temporary crisis until political change, public pressure, or time restored the world as they had previously known it short-term surface responses made reasonable sense.

However, it does seem that there is now a growing realisation that changes in society generally and the NHS in particular are profound and enduring. This has led to a growing receptivity to new sorts of interventions which although promising to be more difficult and demanding, are more likely to deal with the underlying dynamics in the organisation. This has opened the door to a different kind of intervention, one based on a psychodynamic approach.. Thus, one client system, that had been operating under the phantasied illusion that 'everything was really wonderful' and that it 'just required a tweeking of the system' to get things going, discovered after many 'tweekings of the system' (or quick fixes) that the reality was that they 'could not un-lock it'. At this point they came to the conclusion that, although promising to be more difficult and more demanding, it was, nevertheless, essential that they adopt a response which dealt with the underlying dynamics occurring in the organisation.

Regardless of this shift on the part of the client, we are still faced with the problem of providing them with a product that they can understand and accept. In all truth, I do not see this situation as being any different than a normal intervention: that is, we need to start where the client is, and, we need to provide sufficient containment for the client to face the avoided issues. Thus, we need to provide a product that is seen as being quantifiable - in terms of cost and time - and that is replicable in other organisations; and this is what we have aimed to do.

To demonstrate how this can be achieved I want to describe in some depth one particular contract that OPUS competed for and won which I feel is a good example of how it is possible to meet both needs. The project was concerned with organisational stress and our design was based on an intervention process that comprised of two main activities, a two-day Listening Group and a two-day Workshop with other detailed activities between. For this intervention process we were able to present a programme of activities and events, costed out in consultant days, which sufficiently resembled the sort of 'boxed product' the clients were accustomed to. This reduced some of the anxiety generated by the idea of 'looking deeper' into the sources of the presenting problem. Perhaps too, even though it was made explicit from the outset, the familiar 'packaging' meant that the client did not fully take in the less familiar aspects of the proposal, namely, that the consultants would be working interpretively, using transference and counter transference data. However, by gradually introducing this way of working the interpretive methodology leaves the client with a deeper understanding of the dynamics of the organisation.

Some consultants who are used to working in a purely interpretative manner, have seen a conflict between their professional credibility and the demands of such a client. I do not see such a conflict, rather, as Menzies Lyth (1989) has pointed out: the consultant's responsibility lies in helping insights to develop, freeing thinking about problems, helping the client to get away from unhelpful methods of thinking and behaving, facilitating the evolution of ideas for change, and then helping him to bear the anxiety and uncertainty of the change. We cannot do that if we do not get the work and often we will not get the work unless we can design an intervention which the client recognises as acceptable.

There is little point in trying to deal with these organisations in a totally unstructured way even if we thought that was desirable. All that this will do is to create anxiety, an anxiety that develops from a fear of being alone without support. In the first instance, then, the response of the consultant must be in keeping with the current culture. We need to start by looking at 'the way things are done around here': we need to look at the culture of the organisation. But what do we mean by this? In brief terms we can say that organisational culture develops out of the interrelatedness of the members of the organisation and the organisation holding environment (Stapley, 1996). That is, the organisational holding environment - as perceived by the members of the organisation - the construct of the organisation in their minds. As a result of this interrelatedness the members of the organisation adopt forms of behaviour that seem appropriate to them under the conditions imposed upon them by the organisational holding environment. The result is - 'the way things are done around here'.

This is fine as far as it goes. But we need to go further, to understand why the members of the organisation adopt the forms of behaviour that they do, and what shapes the view that they have of the organisation holding environment. One of the difficulties that we have is that even when a group espouses their willingness and ability to be adaptable, there are aspects of them which may be denied, suppressed or disowned and become more or less unconscious. We therefore need a methodology that will provide us with an understanding of these complex phenomena - a methodology that will bring the irrational, the illogical, the exclusively emotional, under rational understanding and control. This requires some form of what psycho-analysts call analysis of the resistance, and the way that we obtain this information is by deliberate intervention and the deciphering of the responses to the intervention.

For this particular intervention, the primary process that we have developed as a means of establishing 'the way things are done around here' is through the two-day event that we call a 'Listening Group'. This is based on an idea that has been developed and used by OPUS over the past ten or so years. This methodology was originally used in a series of Study Days around the theme of 'Understanding Current Societal Dynamics'. In this event members are asked to free associate to their pre-occupations and experiences of stress in their organisation and then to form hypotheses about what is occurring in their organisation.

It is interesting to note that in all three Trusts that we have been working in, one of the responses that we have heard at the end of the Listening Group has been that it has not revealed 'anything new'. From our point of view, this is not surprising. What of course it indicates is that if the matters identified as causing stress in the organisation were rational or surface issues the members of the organisation would have been able to resolve them by one or other of their many attempts. The fact that the problems still remained after so many attempts to resolve them, even though they were causing great distress, indicated that there were underlying psychodynamic problems that were not being addressed.

The following examples demonstrate how using such an approach has permitted us to go beyond the surface issues and provide the opportunity to deal with the underlying causes.

Example 1. In one organisation there was a clear and dysfunctional split between managers and clinicians. At a surface level this was seen as an intractable power struggle between two groups who refused to co-operate. There was some truth in this as health service reforms had resulted in the previously all-powerful medical consultants losing some of that power to management. However, the many attempts to deal with the situation in a rational manner had failed. Gradually it became clear that these groups were being used by the organisation to represent two distinct polarities. Thus, the clinicians were able to represent the 'old' and to hold the cherished belief that health care should be available for everybody no matter what the cost; while the managers were able to represent the 'new' and to hold the belief that health care needed to be managed for the betterment of society as a whole. In using these two groups in this way the organisation was able to avoid coming to terms with the difficulties of accepting that if the groups co-operated they would both have to give up something.

This unbearable dilemma had been obscured by seeing managers as wholly 'bad' and clinicians as wholly 'good', which is how the health service is frequently portrayed in the media. Through the various stages of the intervention process the consultants provided what I shall refer to as a substitute or temporary holding environment. By supporting yet not dominating they were able to reduce the anxiety and provide the confidence for progression. This is a major task for the consultants who must keep themselves in a state where they are receptive to the phenomena they must work with. Being a 'good enough holding environment' means keeping your head while all others are losing theirs. It means gaining people's co-operation before you move them forward. By their reactions the consultants were able to convey back to the members an appropriately modified version of what they had projected. By providing the necessary containment for the members of the organisation and interpreting the behaviour as experienced the clients were able to develop insights and free up their thinking and thus allow the evolution of understanding.

Perhaps not surprisingly, in an intervention where we were focusing on organisational stress, the consultants were also the subject of extremely powerful projections and this has been experienced as very demanding work. It has therefore been a feature of these interventions that in helping the client to bear the anxiety and uncertainty it has been important that the consultants modelled a form of behaviour that included the ability to survive personal attacks and hostility and work with that experience

Example 2. In another organisation the 'bad' object was not a group of managers but one particular manager. At the surface level in this organisation the dysfunction was attributed to this highly autocratic and difficult manager who was being totally unreasonable. Here though it was tolerated because one could always go through the back door to the Chief Executive who would get things done. Again, attempts to deal with this issue at a surface level had failed. When looked at in a systemic manner it became clear that the same sort of polarities existed as in the last example but here we had the added complication that the Chief Executive was being set up as a 'good' object in the senior management team. The other senior managers were also caught up in this process and were avoiding their own anxiety by using these two individuals for their projections.

The effect on the individual who was subject to the 'bad' projections was that he was seen by all as autocratic, uncaring and rather ruthless. Previous attempts to deal with the 'problem' at the individual level - by none other than the Chief Executive - had of course failed. So long as the 'good' object continued to be a receptacle for all 'good' projections, it meant that the 'bad' object' also remained intact. By interpreting and making the unknown known we were able to help the management team develop insights about the underlying dynamics and to begin to understand how they were dealing with anxiety in their organisation. We are still working with this management team and will continue to do so for some while, however, the immediate effect has been a freeing-up of the individual members of the team that has resulted in a greater confidence and optimism.

As was explained above, one of the changes introduced by central government in recent years has been the introduction of a purchaser provider split which creates an internal market for health services. Thus GP's are now budget holders and purchasers of hospital services. It is therefore important that the contracts drawn up between the hospital (providers) and the GP's (purchasers) is clear and workable.

Example 3. In one Trust there was a lack of co-operation between management and clinicians in dealing with purchasers of health care. Management who drew up the contract did not sufficiently collaborate with the internal clinician providers with the result that the contracts were imprecise and inaccurate which more often than not favoured the purchaser and thus created stress for the internal providers. Again, at a rational or surface level, this was something which could seemingly be resolved. What seemed to be stopping it from happening in this organisation, however, was the underlying splitting described above which until resolved would prevent any movement.

As in the previous example, by interpreting the behaviour as experienced to throw light on the underlying dynamic, our intervention permitted the clinicians and managers to free-up their thinking and facilitated them to consider new ways of behaving.

A further difficulty encouraged by societal dynamics is the difficulty of saying 'No'. Clinicians have a long and deep tradition of never saying 'no' to a patient. This is an ethos that is encouraged by such events as extensive media criticism when treatment for a patient is found to be wanting and by the many directives from central government such as Patients' Charters. Societal influence is greater if there is little or no boundary control in the organisation. Where there is no managerial control over how these policies will be implemented within the organisation the full impact is felt at the sharp end by those who are at the boundary or the interface between hospital and patients.

Example 4. We worked with one hospital Trust that had a policy of never closing its doors to patients. There were no procedures for turning patients away no matter what the circumstances. Senior managers hailed this to all and sundry in the community as a bold and successful policy. However, it was a complete denial of the stress and dysfunction caused at the sharp end. Those employed in accident and emergency were faced with the constant pressure of full beds while knowing that even more patients could be on their way. This had various knock on effects, for example, patients sometimes needed to be moved from hospital to hospital by ambulance in the middle of the night to accommodate those brought in. Attempts to deal with this issue at a surface level failed repeatedly despite the stressful circumstances for all concerned.

This situation is also seen to be connected with the split between clinicians and managers. Here, at a surface level managers are relying on the 'goodwill' of the clinicians not to say no, however, the underlying dynamic is that the splitting between managers and clinicians prevents any real discussion about the problem. In this particular intervention we have not, at this stage, been able to help the client to develop this insight, but, we are still trying.

As the above examples have shown, uncovering the underlying, psychological processes in organisations is very similar to the problem that doctors face when dealing with psycho-somatic patients. Initially, the doctor needs to start where the patient is. He or she needs to accept that the effect is as real to the client as is physical disease or damage. However, to immediately inform the patient 'that its really only all in the mind' is unlikely to be believed and also unlikely to be helpful. The physician will therefore try to engage the client by first making a full assessment of their physical symptoms and medical problems until gaining an understanding of the client's response to other treatment before looking at psychological factors. Just as a doctor cannot tell the psychosomatic patient his symptoms have a psychological basis until the patient is ready to consider this, so it is with with non-psychodynamic clients, there is preparatory work to be done This is the approach that OPUS have adopted in our work with large systems in the NHS. In doing so, I believe it is fair to say that we have responded to the client needs and pushed back the boundaries by making our services relevant and attractive to a number of organisations that would not have previously sought our assistance.

Conclusion

So let us try to tease out some of what psychoanalysis would seem to offer in today's organisations. Clearly one is to safeguard the space for reflection for our excessively pressured clients. The boundaries of an appointed meeting time with an individual or a group provide a structure within which certain thoughts can be thought, spoken and tested out, which otherwise might well give way to the demands of action and solution. Also, our training is useful for attending to and processing countertransference and projective identifications, for example how we may get caught up in the managerial drift towards manic omnipotent reparation, or in the despair. One of our contributions certainly is to help people attend to their own emotional experience as data about what is going on in the system. Other functions include drawing attention to danger areas or uncharacteristic behaviour, and keeping alive curiosity and empathy. In a less turbulent work-world, many of our clients might not need us: they are well able to use their own awareness and understanding. Sometimes we help them discover what they already know - their capacity then to 'run with it' is one of the greatest pleasures (and occasionally one of the greatest threats) of the work. Certainly sometimes we can be invaluable in stopping them from embarking on a big quick-fix 'solution', in slowing them down to reflect on causes before rushing to correct defects. Perhaps one of the greatest strengths we bring from the psychoanalytic tradition is patience, being ready to provide the holding and containment which enable the client to attend to what had previously been ignored, and thus to find their own developmental way.

In this paper we have tried to give some evidence of a growing receptivity to psychodynamically- informed ways of thinking about and intervening in organisations, although clearly this is far from being universally the case: It seems that just as basic psychoanalytic concepts - which initially met with scepticism and rejection - gradually found their way into everyday language and thinking, so it is with organisations. But this, in turn, challenges us to position ourselves differently. We are no longer missionaries converting the ignorant heathen (if we ever were, but the image conveys something of the tenor of discussions that one sometimes hears when psychoanalytically-oriented consultants met to discuss their work). Many of the clients are far from being ignorant. Indeed, many are quite capable of offering sophisticated consultancy themselves, but may call on people like us because they lack the time or perhaps more importantly are too much part of the organisational culture and therefore locked into the same defences.

Psychoanalysis at the end of the 20th century is well and truly in the public domain and is now by no means an exclusive field. At the same time, the world is growing more turbulent, stressful and complex. The challenge is to move away from our position as quasi-mystical experts of the unconscious, certainly away from the hubris of seeking to heal or cure organisational pathology, and to mobilise the latent capacities in the complex systems we live and work in. The twentieth century has seen the birth of psychoanalysis, its early battles to survive, its growth into a major movement impacting on the thinking of millions, and also its decline as a therapeutic modality, as others have borrowed and adapted psychoanalytic ideas to produce new approaches which often appeal more to potential clients. At the same time, many organisations are becoming disenchanted with big, 'off-the-peg', glossy interventions which promise much but fail to address the underlying dynamics.

The psychoanalytically-oriented consultant can offer an alternative through interventions which provide containment allowing participants to be in touch with the pain of the work and the elusiveness of solutions;: a 'maternal holding', so to speak, which can open the way to collaborative reflection and meaningful appropriate action-planning. This paper has illustrated some of the current potential of a psychoanalytically-oriented approach to make a significant contribution to the almost unbearable demands of today's world, and has offered some evidence that this world is ready to use what we offer, if we can open ourselves up to working in new ways.

To close, a quote from T. S. Eliot's 'East Coker' (1940):

Home is where we start from. As we grow older

The world becomes stranger, the pattern more complicated......
Old men ought to be explorers

We must be still and still moving

The poem concludes with the words of Mary Queen of Scots which we have used for our title: 'In the end is my beginning'.